PENN CENTER FOR EVIDENCE-BASED PRACTICE

1. PENN CENTER FOR EVIDENCE-BASED PRACTICE Estimating the proportion of reasonably preventable hospital-acquired infections and associated mortality and costs Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice University of Pennsylvania APIC Greater NY - 15th Symposium November 9th, 2011

2. Outline • Review methods and findings of our recent study on the preventability, impact and cost of HAIs • Review guideline recommendations on preventing CAUTIs • Review guideline recommendations on preventing CABSIs • Provide status report on CDC efforts to update the 1999 guideline on preventing SSIs • Conclusion and Discussion

4. Study Background • Hospital acquired infections (HAIs) are common, and numerous strategies to prevent them have been studied • In Oct 2008, Medicare began to encourage hospitals to adopt these strategies by instituting a policy of nonpayment for “reasonably preventable” HAIs, including CABSI, CAUTI and SSI

5. National Standards • CMS Partnership for Patients • Nine core areas of focus, four areas are HAIs: • CAUTI • CABSI • SSI • VAP • Joint Commission’s 2011 National Patient Safety Goals • NPSG.07.04.01 • Use proven guidelines to prevent infection of the blood from central lines • NPSG.07.05.01 • Use proven guidelines to prevent infections after surgery • NPSG.07.06.01 • Use proven guidelines to prevent indwelling catheter-associated urinary tract infections

6. Study Objectives • Some have asserted that not all HAIs are preventable, and that new incentives and mandates punish hospitals that care for patients at high risk of HAIs • To inform discussions regarding the preventability of HAIs, we estimated: • the proportion of HAIs in US hospitals that are reasonably preventable • mortality and costs associated with reasonably preventable HAIs

7. Methods Range of proportion of HAIs that are preventable (%) 1 X Annual number of HAIs and HAI deaths 2 = Range of annual number of preventable HAIs and HAI deaths Range of annual number of preventable HAIs X Incremental cost of HAIs 3 = Range of annual avoidable HAI costs

8. Study Methods • Range of preventability • Use an AHRQ systematic review that examined published interventions to reduce BSI, UTI, SSI, and VAP • We constructed ranges of preventability for each HAI by using the lowest and highest risk reductions reported in the AHRQ review for higher quality US studies published in last decade • Annual number of HAIs and HAI deaths • Use most recently published national data • Incremental cost of an HAI • Perform a systematic review of the published literature • Use data from US studies reporting comprehensive cost analyses adjusted for confounders

9. Study Results: AHRQ Systematic Review 15 studies included in our analysis Ranji SR, Shetty K, Posley KA, Lewis R, Sundaram V, Galvin CM, et al. Volume 6--prevention of healthcare-associated infections. Rockville, MD: Agency for Healthcare Research and Quality; 2007 January 2007. Report No.: AHRQ Publication No. 04(07)-0051-6.

10. VAP Prevention Studies Range of Risk Reductions = 38-55%

11. Range of Risk Reductions for all HAIs

12. Hospital-acquired infections in 2002 Klevens RM, Edwards JR, Richards CL,Jr, Horan TC, Gaynes RP, Pollock DA, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-6.

13. Estimating Preventable HAIs and HAI Deaths

14. Summary estimates of preventable HAIs and HAI deaths for all HAIs

15. Example Search: VAP Cost Studies

16. Systematic Review to Estimate Incremental Cost of HAIs 15 studies included in our analysis

17. VAP Cost Studies

18. Estimated incremental cost per HAI

19. Summary estimates of preventable HAIs, HAI deaths, and HAI costs

20. Summary estimates of preventable infections, deaths, and costs for all HAIs

21. Study Limitations • Survey data we use to calculate number of HAIs and HAI deaths is from 2002 • Difficulty in attributing a death to HAIs • Quality of the HAI reduction and cost studies • Lack of HAI reduction studies that have directly measured death as an outcome

22. Study Conclusions • In those settings examined, reductions in HAIs have never achieved 100%, even with evidence-based infection control strategies • Instead, an upper bound of 65 to 70% risk reduction may exist for BSI and UTI, and approximately 55% for VAP and SSI • Even though 100% preventability may not be attainable, evidence-based infection control strategies could prevent hundreds of thousands of HAIs, and save tens of thousands of lives and billions of dollars • One should not base policy decisions on these estimates without understanding their limitations

23. 2009 Guideline for Prevention of Catheter-associated Urinary Tract Infections Full guideline at http://www.cdc.gov/hicpac/index.html

24. Organization of Recommendations Appropriate urinary catheter use Proper techniques for urinary catheter insertion Proper techniques for urinary catheter maintenance Quality improvement programs Administrative infrastructure Surveillance

25. Priority Recommendations Appropriate Urinary Catheter Use Insert catheters only for appropriate indications, and leave in place only as long as needed. (Category IB) Do not use catheters in patients and nursing home residents for management of incontinence. (Category IB) For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible, preferably within 24 hours, unless there are appropriate indications for continued use. (Category IB) Aseptic Insertion of Urinary Catheters Ensure that only properly trained persons insert and maintain catheters. (Category IB) In acute setting, insert catheters using aseptic technique and sterile equipment. (Category IB) Proper Urinary Catheter Maintenance Maintain a sterile, continuously closed drainage system. (Category IB) 25

26. Indications Table 26

27. 2011 Guideline for the Prevention of Intravascular Catheter-Related Infections Full guideline at http://www.cdc.gov/hicpac/index.html

28. Organization of Recommendations Education, training and staffing Selection of catheters and sites Hand hygiene and aseptic technique Maximum sterile barrier precautions Skin preparation Catheter site dressing regimens Patient cleansing Catheter securement devices Antimicrobial/antiseptic impregnated catheters and cuffs Systemic antibiotic prophylaxis Antibiotic/antiseptic ointments Antibiotic lock prophylaxis, antimicrobial catheter flush and catheter lock prophylaxis

29. Organization of Recommendations (cont) Anticoagulants Replacement of catheters Umbilical catheters Peripheral arterial catheters and pressure monitoring devices Replacement of administration sets Needleless intravascular catheter systems Performance improvement

30. Performance improvement bundle literature referenced by CABSI guideline • Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, PittetD.Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet 2000; 355:1864–8. • BerenholtzSM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004; 32:2014–20. • Frankel HL, Crede WB, Topal JE, Roumanis SA, Devlin MW, Foley AB. Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU. J Am CollSurg 2005; 201:349–58. • PronovostP, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725–32. • Costello JM, Morrow DF, Graham DA, Potter-Bynoe G, Sandora TJ, Laussen PC. Systematic intervention to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit. Pediatrics 2008; 121:915–23. • GalpernD, Guerrero A, Tu A, Fahoum B, Wise L. Effectiveness of a central line bundle campaign on line-associated infections in the intensive care unit. Surgery 2008; 144:492–5. • McKee C, Berkowitz I, Cosgrove SE, et al. Reduction of catheter-associated bloodstream infections in pediatric patients: experimentation and reality. PediatrCrit Care Med 2008; 9:40–6.

33. Pronovost CABSI bundle • Hand hygiene • Maximum barrier precautions • Chlorhexidinesite disinfection • Avoiding the femoral site • Promptly removing unnecessary central venous catheters

34. CABSI bundles (continued) • Educating staff about CABSI prevention • Central venous catheter cart that contained all the necessary supplies • Prompt removal of unnecessary central catheters identified during daily patient rounds • Checklist to ensure adherence to proper practices • Stoppage of procedures in non-emergent situations, if evidence- based practices were not being followed • Feedback to the clinical teams regarding the number of CRBSI episodes and overall rates • Buy-in from the CEO of the participating hospitals that chlorhexidinegluconate products/solutions would be stocked

35. CDC Prevention of SSI Guideline – Update of 1999 Guideline • ARTHROPLASTY Questions • Transfusion • Immunosuppression • Anticoagulation • Surgical attire • Surgical technique • Anesthesia • Environmental • Biofilm • 22 Key questions CORE Questions • Antimicrobial prophylaxis • Glycemiccontrol • Normothermia • Tissue oxygenation • Skin preparation • S. aureuscolonization • Surgical checklists • Bundles • 16 Key Questions

36. Expert Panel & Core Writing Group University of Pennsylvania Center for Evidence-based Practice American College of Surgeons (ACS) American Academy of Orthopaedic Surgeons (AAOS) Association of periOperative Registered Nurses (AORN) CDC/HICPAC SSI Guideline Content Experts Core Writing Group Musculoskeletal Infection Society (MSIS) HICPAC Leads Surgical Infection Society (SIS) European Union HICPAC , Liaison & Ex-officio members Academic Institutions S. aureus, Biofilm, Environmental External and CDC CDC Lead

37. Core Writing Group • HICPAC Committee • Dale W. Bratzler, DO, MPH • William P. Schecter, MD Center for Evidence-based Practice, U Penn • Craig Umscheid MD, MSCE , FACP • RachelKelz, MD , MSCE, FACS • Caroline Reinke, MD, MPH • Brian Leas, MA, MS • Sherry Morgan, RN, MLS, PhD • Centers for Disease Control and Prevention • Sandra I. Berríos-Torres, MD

38. Content Experts Staphylococcus aureus (SA) Colonization • LonnekeG.M. Bode ,MD (Erasmus University, The Netherlands) • SusanHuang,MD (Uof California, Irvine) • JanA.J.W. Kluytmans, MD (Amphia Hospital, The Netherlands) • AriRobicsek,MD (Northshore University Health System) • MarkShirtliff, PhD (University of Maryland) • MargreetVoz,MD (Erasmus University, The Netherlands) • JeffHageman,MHS (CDC) • JohnA. Jernigan,MD, MS (CDC) • AlexKallenMD, MPH (CDC) Biofilm • WilliamCosterton, PhD (Center for Genomic Sciences) • RobinPatel, MD (Mayo Clinic) • MarkShirtliff, PhD (University of Maryland) • RodneyDonlan, PhD (CDC) Environmental • LynneSehulster, PhD (CDC) American Academy of Orthopaedic Surgeons (AAOS) • Javad Parvizi ,MD • John Segreti, MD American College of Surgeons (ACS) • E. Patchen Dellinger, MD Association of periOperative Registered Nurses (AORN) • Joan Blanchard, MSS, BSN, RN, CNOR, CIC • George Allen, PhD, CIC, CNOR Musculolskeletal Infection Society (MSIS) • Elie Berbari, MD • Douglas Osmon, MD Surgical Infection Society (SIS) • Lena M. Napolitano, MD, FACS, FCCP, FCCM • Kamal Itani, MD • Robert Sawyer, MD Academic Institutions • Jan A.J.W. Kluytmans, MD (Amphia Hospital, The Netherlands) • John E. Mazuski, MD, PhD (Washington University, St. Louis) • Bernard Morrey, MD (The Mayo Clinic) • Joseph Solomkin, MD (U of Cincinnati)

39. Key Questions - CORE

40. Key Questions - CORE

41. Key Questions - CORE

42. Key Questions - CORE

43. Key Questions - CORE

44. Key Questions - CORE

45. Key Questions - ARTHROPLASTY

46. Key Questions - ARTHROPLASTY

47. Key Questions - ARTHROPLASTY

48. Key Questions - ARTHROPLASTY

49. Key Questions - ARTHROPLASTY

50. SSI Guideline Timeline Arthroplasty Literature Search (sample) ArthroplastyTitle/Abstract Screen Broad SSI Literature Search CORE Literature Search (sample) CORE Title/Abstract Screen Content Experts Core Writing Group HICPAC Presentation Final Key Questions Preliminary Questions Final Key Topics Guideline Structure Guideline Review Preliminary Topics NEXT STEPS 2010 2011 2012 June Dec June Dec Feb Apr June Preliminary Bibliography Full Text Review Targeted Literature Searches Extraction Finalized GRADE Narrative summaries Post to Federal Register SSI slides courtesy of Sandra I. Berríos-Torres, MD CDC